| The Windsor Place | |
| 81 Windsor Boulevard, Columbus, Mississippi 39702 | |
| (662) 241-5518 | |
| Name | The Windsor Place |
|---|---|
| Location | 81 Windsor Boulevard, Columbus, Mississippi |
| Certified By | Medicare and Medicaid |
| No. of Certified Beds | 140 |
| Occupancy Rate | 90% |
| Medicare ID (CCN) | 255257 |
| Legal Business Name | Windsor Place Nursing Center Inc |
| Ownership Type | For Profit - Corporation |
| NPI Number | 1265449367 |
| Match | Confirmed listed in Medicare enrollment records |
| Organization Name | Windsor Place Nursing Center Inc |
| Address | 81 Windsor Blvd, Columbus, MS 39702 |
| Phone Number | 662-241-5518 |
| Ratings from Surveys (Inspections): | |
| Ratings from Quality Measures: | |
| Ratings from Staffing Data: | |
| Overall Rating: |
|---|
| Staffing Measure | Provider | National Avg. |
|---|---|---|
| Total nurse staff hours per resident per day | 3.57 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.51 | 0.69 |
| Licensed practical nurse (LPN) hours per resident per day | 0.88 | 0.86 |
| Nurse aide hours per resident per day | 2.17 | 2.32 |
| Total nurse staff hours per resident per day on the weekend | 3.04 | 3.42 |
| RN hours per resident per day on the weekend | 0.22 | 0.48 |
| Physical therapist hours per resident per day | 0.04 | 0.07 |
| Total nursing staff turnover | 45% | 45.8% |
| Registered nurse turnover | 35.7% | 42.9% |
| Number of administrators who have left the nursing home | 1 | 0.5 |
| Cited for abuse, neglect or exploitation of residents (Care Compare abuse icon) | No |
| Number of Fines | 2 |
| Total Amount of Fines in Dollars | $10,839 |
| Number of Payment Denials | 0 |
| Total Number of Penalties | 2 |
| Date | Deficiency | Harm Level | Status |
|---|---|---|---|
| Oct 9, 2024 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted F0655, Resident Assessment and Care Planning, Standard inspection | Actual harm, isolated | Corrected by Nov 6, 2024 |
| Oct 9, 2024 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. F0686, Quality of Life and Care, Standard inspection | Actual harm, isolated | Corrected by Nov 6, 2024 |
| Oct 9, 2024 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. F0812, Nutrition and Dietary, Standard inspection | Potential for harm, widespread | Corrected by Nov 6, 2024 |
| Oct 9, 2024 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. F0755, Pharmacy Service, Standard inspection | Potential for harm, pattern | Corrected by Nov 6, 2024 |
| Oct 9, 2024 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. F0584, Resident Rights, Standard inspection | Potential for harm, isolated | Corrected by Nov 6, 2024 |
| Oct 9, 2024 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. F0656, Resident Assessment and Care Planning, Standard inspection | Potential for harm, isolated | Corrected by Nov 6, 2024 |
| Oct 9, 2024 | Provide care and assistance to perform activities of daily living for any resident who is unable. F0677, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by Nov 6, 2024 |
| Oct 9, 2024 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. F0689, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by Nov 6, 2024 |
| Oct 9, 2024 | Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. F0700, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by Nov 6, 2024 |
| Oct 9, 2024 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. F0761, Pharmacy Service, Standard inspection | Potential for harm, isolated | Corrected by Nov 6, 2024 |
| Oct 9, 2024 | Provide and implement an infection prevention and control program. F0880, Infection Control, Standard inspection | Potential for harm, isolated | Corrected by Nov 6, 2024 |
| May 16, 2024 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. F0580, Resident Rights, Complaint inspection | Potential for harm, isolated | Corrected by Jun 20, 2024 |
| Jul 27, 2023 | Honor the resident's right to organize and participate in resident/family groups in the facility. F0565, Resident Rights, Standard inspection | Potential for harm, isolated | Corrected by Sep 5, 2023 |
| Jul 27, 2023 | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. F0578, Resident Rights, Standard inspection | Potential for harm, isolated | Corrected by Sep 5, 2023 |
| Jul 27, 2023 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. F0600, Freedom from Abuse, Neglect, and Exploitation, Standard inspection | Potential for harm, isolated | Corrected by Sep 5, 2023 |
| Jul 27, 2023 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. F0609, Freedom from Abuse, Neglect, and Exploitation, Standard inspection | Potential for harm, isolated | Corrected by Sep 5, 2023 |
| Jul 27, 2023 | Respond appropriately to all alleged violations. F0610, Freedom from Abuse, Neglect, and Exploitation, Standard inspection | Potential for harm, isolated | Corrected by Sep 5, 2023 |
| Jul 27, 2023 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. F0725, Nursing and Physician Services, Standard inspection | Potential for harm, isolated | Corrected by Sep 5, 2023 |
| Jul 27, 2023 | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. F0758, Pharmacy Service, Standard inspection | Potential for harm, isolated | Corrected by Sep 5, 2023 |
| Jul 27, 2023 | Provide and implement an infection prevention and control program. F0880, Infection Control, Standard inspection | Potential for harm, isolated | Corrected by Sep 5, 2023 |
| Oct 28, 2021 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. F0657, Resident Assessment and Care Planning, Standard inspection | Actual harm, pattern | Corrected by Nov 18, 2021 |
| Oct 28, 2021 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. F0689, Quality of Life and Care, Standard inspection | Actual harm, pattern | Corrected by Nov 18, 2021 |
| Oct 28, 2021 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. F0812, Nutrition and Dietary, Standard inspection | Potential for harm, pattern | Corrected by Nov 18, 2021 |
| Oct 28, 2021 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. F0623, Resident Rights, Standard inspection | Potential for harm, isolated | Corrected by Nov 18, 2021 |
| Oct 28, 2021 | Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. F0640, Resident Assessment and Care Planning, Standard inspection | Potential for harm, isolated | Corrected by Nov 18, 2021 |
| Oct 28, 2021 | Have the Quality Assessment and Assurance group have the required members and meet at least quarterly F0868, Administration, Standard inspection | Potential for harm, isolated | Corrected by Nov 18, 2021 |
| Quality Measure | Provider | National Avg. |
|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | 32 | 13.87 |
| Percentage of long-stay residents who lose too much weight | 3.77 | 5.19 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.25 | 0.82 |
| Percentage of long-stay residents with a urinary tract infection | 7.47 | 1.59 |
| Percentage of long-stay residents who have depressive symptoms | 0 | 12.8 |
| Percentage of long-stay residents who were physically restrained | 0 | 0.13 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.71 | 3.23 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.67 | 93.55 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.71 | 82.04 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4 | 1.56 |
| Percentage of long-stay residents whose ability to walk independently worsened | 19.68 | 14.07 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.6 | 19.52 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.8 | 95.46 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 77.67 | 79.75 |
| Percentage of long-stay residents with pressure ulcers | 5.03 | 4.62 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.17 | 19.01 |
| Percentage of long-stay residents who received an antipsychotic medication | 30.33 | 15.38 |
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